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July 9, 2006

Diagnosis and Symptoms

Question from San Diego, California, USA:

My seven year old daughter had been exhibiting signs that, to me, seem hypoglycemic in nature: angry outbursts, ravenous hunger and then won't eat, grey looking skin, spacey and confused. She woke up with what appeared to be a yeast infection and had croup, a sore throat and, generally, just didn't feel well. I took her to the pediatrician and was told she had a small amount of glucose in her urine. They stuck her with a lancet and her reading was 275 mg/dl [15.3 mmol/L]. She was also on a course of prednisone for the croup at that same time. She was immediately diagnosed with type 1 diabetes and we were told that we had "caught it early." We were sent for laboratory work and to the endocrinologist the following day where we started insulin shots. We then had a tough time keeping her sugars up during the day, almost force feeding her to get them up. We went for a second opinion with the top endocrinologist at Children's Hospital in San Diego who looked over the laboratory work and said she had tested negative for islet cell and GAD-65 antibodies and was, therefore, misdiagnosed with diabetes in the first place. He explained that when you are ill, your body responds to infection or stress by releasing other hormones, cortisol and adrenaline which in turn, can increase your glucose numbers. He assured us that since she tested negative for the antibodies associated with diabetes, our daughter is at no risk for diabetes. We took her off the insulin two days ago and since then, her readings are perfectly within range (84 mg/dl [4.7 mmol/L] fasting, 112 mg/dl [6.2 mmol/L] after breakfast and nothing above 120 mg/dl [6.7 mmol/L] as of this moment). The original doctor stands by her diagnosis and claims that our daughter is indeed in the pre-diabetic stages. What do we believe and how do we proceed to be certain we are not missing something? Should we just let go and believe that she is okay?

Answer:

You definitely should not ignore any of this. I suspect that both doctors are correct, but answering slightly different questions. Prednisone certainly can induce diabetes in someone who is genetically susceptible. Antibodies are only one of the ways we determine such susceptibility, but they are not definitive. If positive, this is more conclusive than if negative. Many children, and even adults, have type 1 diabetes with negative antibodies because the antibody testing is not 100% So, as to your child, I would recommend ongoing blood glucose monitoring so that you can determine and provide information for your endocrinologists as to what is actually occurring with or without symptoms. High risk times include periods of growth and also if prednisone or other such steroids are needed in the future, as well as any type of infection (virus, bacterial, etc.). The longer she goes without needing insulin and with perfectly normal pre-meal blood sugar values (less than 100 mg/dl [5.6 mmol/L]), as well as perfectly normal postprandial blood sugars (i.e., less than 126 mg/dl [7.0 mmol/L] – some would be more lenient and say less than 140 mg/dl [7.8 mmol/L]) – the less likely that frank diabetes will be diagnosed or she will need insulin the future. Periodic A1c tests, as well as antibody tests, a few more times would also be helpful in sorting this out. Time will be your best guide as to what she needs done coupled with periodic blood sugar results.

SB